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Based on dozens of interviews and access to previously unreleased military studies, documents and emails, NPR and ProPublica have found that from the battlefield to the homefront the military's doctors and screening systems routinely miss brain trauma in soldiers. As a result, soldiers haven't been getting treatment. June 7, 2010
The military medical system is failing to diagnose brain injuries in troops who served in Iraq and Afghanistan, many of whom receive little or no treatment for lingering health problems, an investigation by NPR and ProPublica has found.
So-called mild traumatic brain injury has been called one of the wars' signature wounds. Shock waves from roadside bombs can ripple through soldiers’ brains, causing damage that sometimes leaves no visible scars but may cause lasting mental and physical harm.
Officially, military figures say about 115,000 troops have suffered mild traumatic brain injuries since the wars began. But top Army officials acknowledged in interviews that those statistics likely understate the true toll. Tens of thousands of troops with such wounds have gone uncounted, according to unpublished military research obtained by NPR and ProPublica.
"When someone's missing a limb, you can see that," said Sgt. William Fraas, a Bronze Star recipient who survived several roadside blasts in Iraq. He can no longer drive, or remember simple lists of jobs to do around the house. "When someone has a brain injury, you can't see it, but it's still serious."
In 2007, under enormous public pressure, military leaders pledged to fix problems in diagnosing and treating brain injuries. Yet despite the hundreds of millions of dollars pumped into the effort since then, critical parts of this promise remain unfulfilled.
Over four months, we examined government records, previously undisclosed studies and private correspondence between senior medical officials. We conducted interviews with scores of soldiers, experts and military leaders.
Among our findings:
From the battlefield to the homefront, the military’s doctors and screening systems routinely miss brain trauma in soldiers. One of the military tests fails to catch as many as 40 percent of concussions, a recent unpublished study concluded. A second exam, on which the Pentagon has spent millions, yields results that top medical officials call about as reliable as a coin flip.
Even when military doctors diagnose head injuries, that information often doesn't make it into soldiers' permanent medical files. Handheld medical devices designed to transmit data have failed in the austere terrain of the war zones. Paper records from Iraq and Afghanistan have been lost, burned or abandoned in warehouses, officials say, when no one knew where to ship them.
Without diagnosis and official documentation, soldiers with head wounds have had to battle for appropriate treatment. Some received psychotropic drugs instead of rehabilitative therapy that could help retrain their brains. Others say they have received no treatment at all, or have been branded as malingerers.
In the civilian world, there is growing consensus about the danger of ignoring head trauma: Athletes and car accident victims are routinely tested for brain injuries and are restricted from activities that could result in further blows to the head.
NPR and ProPublica uncovered previously unreleased military studies, documents and emails.
'We Still Have A Big Problem'
But the military continues to overlook similarly wounded soldiers, a reflection of ambivalence about these wounds at the highest levels, our reporting shows. Some senior Army medical officers remain skeptical that mild traumatic brain injuries are responsible for soldiers' troubles with memory, concentration and mental focus.
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Did you or a loved one suffer a traumatic brain injury while serving? ProPublica and NPR want to hear you story. Tell us how you survived your battle with TBI.
Civilian research shows that an estimated 5 percent to 15 percent of people with mild traumatic brain injury have persistent difficulty with such cognitive problems.
"It's obvious that we are significantly underestimating and underreporting the true burden of traumatic brain injury," said Maj. Remington Nevin, an Army epidemiologist who served in Afghanistan and has worked to improve documentation of TBIs and other brain injuries. "This is an issue which is causing real harm. And the senior levels of leadership that should be responsible for this issue either don't care, can't understand the problem due to lack of experience, or are so disengaged that they haven't fixed it."
When Lt. Gen. Eric Schoomaker, the Army's most senior medical officer, learned that NPR and ProPublica were asking questions about the military’s handling of traumatic brain injuries, he initially instructed local medical commanders not to speak to us.
"We have some obvious vulnerabilities here as we have worked to better understand the nature of our soldiers' injuries and to manage them in a standardized fashion," he wrote in an e-mail sent to bases across the country. "I do not want any more interviews at a local level."
When confronted with the findings later, however, he acknowledged shortcomings in the military's diagnosing and documenting of head traumas.
"We still have a big problem and I readily admit it," said Schoomaker, the Army's surgeon general. "That is a black hole of information that we need to have closed."
Brig. Gen. Loree Sutton, who oversees brain injury issues for the Pentagon, said the military had made great strides in improving attitudes towards the detection and treatment of traumatic brain injury.
The military is considering implementing a new policy to mandate the temporary removal from the battlefield of soldiers exposed to nearby blasts. Later this year, the Pentagon expects to open a cutting-edge center for brain and psychological injuries, which will treat about 500 soldiers annually.
William Frass at rehab
EnlargeBlake Gordon/Aurora Photos for NPR
William Fraas during occupational therapy at Mentis Neuro Rehabilitation Center in El Paso. Fraas survived several roadside blasts in Iraq, but suffered brain damage. Blake Gordon/Aurora Photos for NPR
William Fraas during occupational therapy at Mentis Neuro Rehabilitation Center in El Paso. Fraas survived several roadside blasts in Iraq, but suffered brain damage.
"This journey of cultural transformation, it is a journey not for the faint of heart," Sutton said. "At the end of our journeys, at the end of our travels, what we must ensure is, we must ensure that we have consistent standards of excellence across the board. Are we there yet? Of course we’re not there yet." Left Behind
Soldiers like Michelle Dyarman wonder what’s taking so long. Dyarman, a former major in the Army reserves, was involved in two roadside bomb attacks and a Humvee accident in Iraq in 2005.
Today, the former dean's list student struggles to read a newspaper article. She has pounding headaches. She has trouble remembering the address of the farmhouse where she grew up in the hills of central Pennsylvania.
For years, Dyarman fought with Army doctors who did not believe that she was suffering lasting effects from the blows to her head. Instead, they diagnosed her with an array of maladies from a headache syndrome to a mood disorder.
"One of the first things you learn as a soldier is that you never leave a man behind," said Dyarman, 45. "I was left behind."
In 2008, after Dyarman retired from the Army, Veterans Affairs doctors linked her cognitive problems to her head traumas.
Dyarman has returned to her civilian job inspecting radiological devices for the state, but colleagues say she turns in reports with lots of blanks; they cover for her.
Dyarman’s 67-year-old father, John, looks after her at home, balancing her checkbook, reminding her to turn the oven on before cooking. The joyful, bright child he raised, the first in the family to attend college, is gone, forever gone.
"It hurts me, too," he said, growing upset as he spoke. "That's my daughter sitting there, all screwed up. She's not the kid she was." Walkie Talkies
Better armor and battlefield medicine mean troops survive explosions that would have killed an earlier generation. But blast waves from roadside bombs, insurgents' most common weapon, can still damage the brain.
The shockwaves can pass through helmets, skulls and through the brain, damaging its cells and circuits in ways that are still not fully understood. Then, secondary trauma can follow, such as sending a soldier tumbling inside a vehicle or hurling into a wall, shaking the brain against the skull.
Not all brain injuries are alike. Doctors classify them as moderate or severe if patients are knocked unconscious for more than 30 minutes. The signs of trauma are obvious in these cases and medical scanning devices, like MRIs, can detect internal damage.
But the most common head injuries in Iraq and Afghanistan are so-called mild traumatic brain injuries. These are harder to detect. Scanning devices available on the battlefield typically don't show any damage. Recent studies suggest that breakdowns occur at the cellular level, with cell walls deteriorating and impeding normal chemical reactions.
Doctors debate how best to categorize and describe such injuries. Some say the term mild traumatic brain injury best describes what happens to the brain. Others prefer to use concussion, insisting the word carries less stigma than brain injury.
Whatever the description, most soldiers recover fully within weeks, military studies show. Headaches fade, mental fogs clear and they are back on the battlefield.
For a minority, however, mental and physical problems can persist for months or years. Nobody is sure how many soldiers who suffer mild traumatic brain injury will have long-term repercussions. Researchers call the 5 percent to 15 percent of civilians who endure persistent symptoms the "miserable minority."
A study published last year in the Journal of Head Trauma Rehabilitation found that, of the 900 soldiers in one battle-hardened Army brigade who suffered brain injuries, almost 40 percent reported having at least one symptom weeks or months later.
The long-term effects of mild traumatic brain injuries can be devastating, belying their name. Soldiers can endure a range of symptoms, from headaches, dizziness and vertigo to problems with memory and reasoning. Soldiers in the field may react more slowly. Once they go home, some commanders who led units across battlefields can no longer drive a car down the street. They can't understand a paragraph they have just read, or comprehend their children's homework. Fundamentally, they tell spouses and loved ones, they no longer think straight.
Such soldiers are sometimes called "walkie talkies" — unlike comrades with missing limbs or severe head wounds, they can walk and talk. But the cognitive impairments they face can be severe.
Dr. Keith Cicerone from NJ
EnlargeDavid Gilkey/NPR
Doctor Keith Cicerone works in neuropsychology and cognitive rehabilitation at the JFK-Johnson Rehabilitation Institute in New Jersey. All of his patients have suffered traumatic brain injuries. Doctors at the institute highly recommend cognitive rehabilitation over other forms of treatment.
"These are people who go on to live with a lifelong chronic disability," said Keith Cicerone, a leading researcher in the field. “It is going to be terrifically disruptive to their functioning."
An increasing number of brain-injury specialists say the best way to treat patients with lasting symptoms is to get them into cognitive rehabilitation therapy as soon as possible. That was the consensus recommendation of 50 civilian and military experts gathered by the Pentagon in 2009 to discuss how to treat soldiers.
Such therapy can retrain the brain to compensate for deficits in memory, decision-making and multitasking.
A soldier whose injuries are not diagnosed or documented misses out on the chance to get this level of care — and the hope for recovery it offers, say veterans advocates, soldiers and their families.
"Talk is cheap. It is easy to say we honor our servicemen," said Cicerone, who has helped the military develop recommendations for appropriate treatments for soldiers with brain injuries. "I don’t think the services that we are giving to those servicemen honors those servicemen." Missing Records
The military’s handling of traumatic brain injuries has drawn heated criticism before.
ABC News reporter Bob Woodruff chronicled the difficulties soldiers faced in getting treatment for head traumas after recovering from one himself, which he suffered in a 2006 roadside bombing in Iraq. The following year, a Washington Post series about substandard conditions at Walter Reed Army Medical Hospital described the plight of several soldiers with brain injuries.
Members of Congress responded by dedicating more than $1.7 billion to research and treatment of traumatic brain injury and post-traumatic stress, a psychological disorder common among soldiers returning from war. They passed a law requiring the military to test soldiers’ cognitive functions before and after deployment so brain injuries wouldn’t go undetected.
But leaders’ zeal to improve care quickly encountered a host of obstacles. There was no agreement within the military on how to diagnose concussions, or even a standardized way to code such incidents on soldiers’ medical records.
Good intentions banged up against the military's gung-ho culture. To remain with comrades, soldiers often shake off blasts and ignore symptoms. Commanders sometimes ignore them, too, under pressure to keep soldiers in the field. Medics, overwhelmed with treating life-threatening injuries, may lack the time or training to recognize a concussion.
The NPR and ProPublica investigation, however, indicates that the military did little to overcome those battlefield hurdles. They waited for soldiers to seek medical attention, rather than actively seeking to evaluate those in blasts.
The military also has repeatedly bungled efforts to improve documentation of brain injuries, the investigation found.
Several senior medical officers said soldiers’ paper records were often lost or destroyed, especially early in the wars. Some were archived in storage containers, then abandoned as medical units rotated out of the war zones.
Lt. Col. Mike Russell, the Army's senior neuropsychologist, said fellow medical officers told him stories of burning soldiers' records rather than leaving them in Iraq where anyone might find them.
"The reality is that for the first several years in Iraq everything was burned. If you were trying to dispose of something, you took it out and you put it in a burn pan and you burned it," said Russell, who served two tours in Iraq. "That’s how things were done."
To improve recordkeeping, medics began using pricey handheld devices to track injuries electronically. But they often broke or were unable to connect with the military's stateside databases because of a lack of adequate Internet bandwidth, said Nevin, the Army epidemiologist.
"These systems simply were not designed for war the way we fight it," he said.
In 2007, Nevin began to warn higher-ups that information was being lost. His concerns were ignored, he said. While communications have improved in Iraq, Afghanistan remains a concern.
That same year, clinicians interviewed soldiers about whether they had suffered concussions for an unpublished Army analysis, which was reviewed by NPR and ProPublica. They found that the military files showed no record of concussions in more than 70 percent of soldiers who reported such injuries to the clinicians.
Nevin said that without documentation of wounds, soldiers could have trouble obtaining treatment, even when they report they can’t think, or read, or comprehend instructions normally anymore.
Doctors might say, "there’s no evidence you were in a blast," Nevin said. “I don’t see it in your medical records. So stop complaining.”
Problems documenting brain injuries continue.
Russell said that during a tour of Iraq last year, he examined five soldiers the day after they were injured in a January 2009 rocket attack. The medical staff had noted shrapnel injuries, but Russell said they failed to diagnose the soldiers' concussions.
The symptoms were "classic," Russell said. The soldiers had "dazed" expressions, and were slow to respond to questions.
"I found out several of them had significant gaps in their memory," Russell said. "It wasn’t clear how long they were unconscious for, but the last thing they remember is they were playing video games. The next thing they remember, they are outside the trailer."
Another doctor told NPR and ProPublica of finding soldiers with undocumented mild traumatic brain injuries in Afghanistan as recently as February 2010.
Victor Medina suffered brain damage when an IED hit his truck in Iraq
EnlargeBlake Gordon/Aurora Photos for NPR
Sgt. Victor Medina suffered brain damage when an IED hit his truck in Iraq. As part of a rehabilitation exercise, Jimmy Moody times how long Victor can balance, at the Mentis rehabilitation facility in El Paso, Texas. Blake Gordon/Aurora Photos for NPR
Sgt. Victor Medina suffered brain damage when an IED hit his truck in Iraq. As part of a rehabilitation exercise, Jimmy Moody times how long Victor can balance, at the Mentis rehabilitation facility in El Paso, Texas.
"It's still happening, there's no doubt," said the military doctor, who did not want to be named for fear of retribution Screened Out
After the Walter Reed scandal, the military instituted a series of screens to better identify service members with brain injuries. Soldiers take an exam before deploying to a war zone, another after a possible concussion in theater, and a third after returning home.
But each of these screens has proved to have critical flaws.
The military uses an exam called the Automated Neuropsychological Assessment Metrics, or ANAM, to establish a baseline for soldiers’ cognitive abilities. The ANAM is composed of 29 separate tests that measure reaction times and reasoning capabilities. But the military, looking to streamline the process, decided to use only six of those tests.
Doubts immediately arose about the exam, which had never been scientifically validated. Schoomaker, the Army surgeon general, recently told Congress that the ANAM was "fraught with problems" and that "as a screening tool,” it was “basically a coin flip."
Military clinicians have administered the exam to more than 580,000 soldiers, costing the military millions of dollars per year, but have accessed the results for diagnostic purposes only about 1,500 times.
Rep. Bill Pascrell Jr., D-N.J., who has led efforts to improve the treatment and study of brain injuries, accused the military of ignoring the Congressional directive.
"We are not doing service to our bravest," Pascrell said. "There needs to be a sense of urgency on this issue. We are not doing justice."
Once in theater, soldiers are supposed to take the Military Acute Concussion Evaluation, or MACE, to check for cognitive problems after blasts or other blows to the head.
But in interviews, soldiers said they frequently gamed the test, memorizing answers beforehand or getting tips from the medics who administer it.
Just last summer, Sgt. Victor Medina was leading a convoy in southern Iraq when a roadside bomb exploded. He was knocked unconscious for 20 minutes.
Afterwards, Medina had trouble following what other soldiers were saying. He began slurring his words. But he said the medic helped him to pass his MACE test, repeating questions until he answered them correctly.
"I wanted to be back with my soldiers," he said. “I didn't argue about it.".
Senior military officials said problems with the MACE were common knowledge.
"There's considerable evidence that people were being coached or just practicing," said Russell, the senior neuropsychologist. "They don’t want to be sidelined for a concussion. They don’t want to be taken out of play."
If cases of brain trauma get past the battlefield screen, a third test — the post-deployment health assessment, or PDHA — is supposed to catch them when soldiers return home.
But a recent study, as yet unpublished, shows this safety net may be failing, too.
When soldiers at Fort Carson, Colo., were given a more thorough exam bolstered by clinical interviews, researchers found that as many as 40 percent of them had mild traumatic brain injuries that the PDHA had missed.
In a 2007 e-mail, a senior military official bluntly acknowledged the shortcomings of PDHA exams, describing them as "coarse, high-level screening tools that are often applied in a suboptimal assembly line manner with little privacy” and under “huge time constraints."
Col. Heidi Terrio, who carried out the Fort Carson study, said the military's screens must be improved.
"It's our belief that we need to document everyone who sustained a concussion," she said. "It's for the benefit of the Army and the benefit of the family and the soldier to get treatment right away."
Gen. Peter Chiarelli, the Army's second in command, acknowledged that the military has not made the progress it promised in diagnosing brain injuries.
"I have frustration about where we are on this particular problem," Chiarelli said.
Frontline: The Wounded Platoon
This Frontline documentary follows Charlie Company's Third Platoon in Iraq. When the soldiers return home, some adjust well to civilian life, while others struggle with post traumatic stress and traumatic brain injuries. One is in prison, having pled guilty to participation in the murder of another soldier.
Frontline documentary on Charlie Company's Third Platoon
Frontline Watch Frontline's 'The Wounded Platoon'
Fundamentally, he said, soldiers, military officers and the public needed to take concussions seriously.
"We’ve got to change the culture of the Army. We’ve got to change the culture of society," he said, adding later, "We don’t want to recognize things we can’t see." Skeptics
The shift Chiarelli envisions may be impossible without buy-in from senior military medical officials, some of whom are skeptical about the long-term harm caused by mild traumatic brain injuries.
One of Schoomaker’s chief scientific advisors, retired Army psychiatrist Charles Hoge, has been openly critical of those who are predisposed to attribute symptoms like memory loss and concentration problems to mild traumatic brain injury.
In 2009, he wrote a opinion piece in the New England Journal of Medicine that said the "illusory demands of mild TBI" might wind up hobbling the military with high costs for unnecessary treatment. Recently, Hoge questioned the importance of even identifying mild traumatic brain injury accurately.
"What's the harm in missing the diagnosis of mild TBI?" he wrote to a colleague in an April 2010 e-mail obtained by NPR and ProPublica. He said doctors could treat patients’ symptoms regardless of their underlying cause.
In an interview, Hoge said, "I've been concerned about the potential for misdiagnosis, that symptoms are being attributed to mild traumatic brain injury when in fact they're caused by other" conditions. He noted that a study he conducted, published in the New England Journal of Medicine, "found that PTSD really was the driver of symptoms. That doesn't mean that (mild) TBI isn't important. It is important. It's very important."
Other experts called Hoge’s posture toward mild TBI troubling.
To be sure, brain injuries and PTSD sometimes share common symptoms and co-exist in soldiers, brought on by the same terrifying events. But treatments for the conditions differ, they said. A typical PTSD program, for instance, doesn't provide cognitive rehabilitation therapy or treat balance issues. Sleep medication given to someone with nightmares associated with PTSD might leave a brain-injured patient overly sedated, without having a therapeutic effect.
"I'm always concerned about people trivializing and minimizing concussion," said James Kelly, a leading researcher who now heads a cutting-edge Pentagon treatment center for traumatic brain injury. "You still have to get the diagnosis right. It does matter. If we lump everything together, we're going to miss the opportunity to treat people properly." The Fight For Treatment
At her family farm outside Hanover, Pa., Michelle Dyarman has a large box overflowing with medical charts, letters and manila envelopes. They are the record of her fight over the past five years to get diagnosis and treatment for her traumatic brain injury.
After her last roadside blast in Baghdad, which killed two colleagues, Dyarman wound up at Walter Reed for treatment of post-traumatic stress.
Over the course of two and a half years, she received drugs for depression and nightmares. She got physical therapy for injuries to her back and neck. A rehabilitation specialist gave her a computer program to help improve her memory.
But it wasn't until she began talking with fellow patients that she heard the term mild traumatic brain injury. As she began to research her symptoms, she asked a neurologist whether the blasts might have damaged her brain.
Records show the neurologist dismissed the notion that Dyarman's "minor head concussions" were the source of her troubles, and said her symptoms were "likely substantially attributable" to PTSD and migraine headaches.
"It was disappointing," she said. "It felt like nobody cared."
When she was later given a diagnosis of traumatic brain injury by Veterans Affairs doctors, she said she felt vindicated, yet cheated all at once.
"I always put the military first, even before my family and friends. Now looking back, I wonder if I did the right thing," she said. "I served my country. Now what's my country doing for me?"
ProPublica is a nonprofit investigative news organization.
Based on dozens of interviews and access to previously unreleased military studies, documents and e-mails, NPR and ProPublica have found that from the battlefield to the homefront the military's doctors and screening systems routinely miss brain trauma in soldiers. As a result, soldiers haven't been getting treatment. Part 1: The military medical system is failing to diagnose brain injuries in troops who served in Iraq and Afghanistan. Part 2: Even when traumatic brain injury is diagnosed, many soldiers have to fight for adequate treatment. June 9, 2010
At the rapidly expanding base in Fort Bliss, Texas, along the U.S.-Mexico border, the military is racing to build new homes for 10,000 additional soldiers. Cranes stack prefabricated containers like children's blocks to erect barracks overnight. Bulldozers grind sagebrush desert into roads and runways.
Just down the street from the construction boom squats a tan, featureless building about the size of a convenience store. Completed nearly a year ago, it remains unopened, the doors locked.
Building 805 was supposed to house a clinic for traumatic brain injury, often called the signature wound of the wars in Iraq and Afghanistan. Instead, it has become a symbol for soldiers here of what they call commanders' indifference to their problems.
"The system here has no mercy," said Sgt. Victor Medina, a decorated combat veteran who fought to receive treatment at Fort Bliss after suffering a brain injury during a roadside blast in Iraq last June. Since the explosion, Medina has had trouble reading, comprehending and doing simple tasks. "It's struggle after struggle."
Previously, NPR and ProPublica reported that the military has failed to diagnose brain injuries in troops who served in Iraq and Afghanistan. Mild traumatic brain injuries, which doctors also call concussions, do not leave visible scars but can cause lasting mental and physical problems.
At Fort Bliss, we found that even soldiers who are diagnosed with such injuries often do not receive the treatment they need.
Most specialists say it is critical for patients who show lingering effects from head trauma to get intensive therapy as soon as possible. In the civilian world, such therapy is increasingly seen as the best way to minimize permanent damage, helping to retrain the mind to compensate for deficits.
Yet brain-injured soldiers at Fort Bliss have had to wait weeks and sometimes months just to get appointments with doctors, medical records show. Many have received far less therapy than is typical at well-regarded civilian clinics. In some instances, Fort Bliss medical officers have suggested that the soldiers are malingerers or that the main root of their cognitive problems is psychological.
Getting Care For Traumatic Brain Injury
"Here you have all these soldiers looking for help, and it was just getting swept under the carpet," said Sgt. Brandon Sanford, 28, a dog handler who survived two roadside blasts in Iraq. Sanford endured a year of balance problems and mental fog before Fort Bliss officials sent him for cognitive therapy. "I served my country. I've got an injury to prove it."
It is impossible for civilians to know how Fort Bliss' care for brain-injured soldiers compares in quality or scale to that of other bases. Base officials would not give NPR and ProPublica data on how many soldiers are being treated there and the Pentagon would not provide this information for bases elsewhere.
Tell Us Your Story
Did you or a loved one suffer a traumatic brain injury while serving? ProPublica and NPR want to hear you story. Tell us about your experience with TBI.
Fort Bliss — the third-largest base in the U.S. military and a vital nerve center for deploying and returning troops — is supposed to be among the best. In 2007, the Pentagon designated it as one of 20 bases nationally that would develop augmented treatment programs for traumatic brain injury.
Yet while base commanders have spent more than $3 billion to expand and improve Fort Bliss over the past several years, they have directed just $5 million to facilities and clinicians to treat TBI. The program had no full-time director until October 2009. A neuropsychologist was hired only recently, after a two-year search.
Fort Bliss' commander, Maj. Gen. Howard Bromberg, declined repeated requests for an interview. Col. James Baunchalk, the base hospital's commander, acknowledged that the TBI program had encountered some delays, but said that it now had 12 clinicians — four full-time and eight part-time — who were delivering comprehensive care.
"I honestly believe that we've done a good job of meeting the needs for the community," Baunchalk said.
He promised in April that Building 805 would open by the end of May, saying they were just waiting until computer cabling was installed.
Apparently, they missed their deadline. As of early June, the clinic to screen soldiers for traumatic brain injury had not opened its doors to a single patient. The Soldiers
Traumatic brain injuries are among the most common wounds sustained in Iraq and Afghanistan. Shock waves from bombs can pass through helmets and through the brain. Secondary trauma can occur when soldiers are thrown up against vehicles or walls, shaking the brain again.
Officially, the military says about 150,000 soldiers have suffered some form of brain injury since the wars began. But a 2008 Rand study suggests the toll is much higher, perhaps more than 400,000 troops. The most common type are so-called mild traumatic brain injuries. Most people recover quickly from such injuries, but studies have shown between 5 percent and 15 percent of patients may suffer long-term problems.
NPR and ProPublica uncovered previously unreleased military studies, documents and e-mails.
NPR and ProPublica interviewed more than a dozen soldiers at Fort Bliss who are among that so-called miserable minority. All were diagnosed by military doctors with at least one mild traumatic brain injury. All had persistent symptoms, ranging from headaches and vertigo to difficulties with memory and reasoning.
They described the bewildering ways in which their injuries had changed them. A sergeant who once commanded 60 men in battle got lost in a supermarket. A soldier who once plotted sniper attacks could no longer assemble a bird house. Most of them did not want their names used, for fear of harm to their military careers.
All felt the treatment they received was inadequate. At leading neurocognitive rehabilitation centers, some patients with mild traumatic brain injury often receive three to six hours a day of therapy for months from teams of highly trained specialists.
By contrast, many soldiers at Fort Bliss attended two to four hours of cognitive treatment per week. For some soldiers, weeks passed by with little or no treatment. The therapists who provided the soldier with speech and occupational therapy for their brain injuries sometimes had only minimal training in cognitive rehabilitation, records show.
Staffing shortfalls also meant soldier had long waits before beginning rehabilitative therapies. While clinical research is still developing, the consensus recommendation of a group of military and civilian experts convened by the Pentagon last year was to provide rehabilitation therapy as promptly as possible.
"The longer you go without therapy, the greater likelihood there is of falling into what I would call a mental disuse syndrome, where the brain is not being used at the same level," said Keith Cicerone, a leading rehabilitation researcher and the director of neuropsychology at the JFK Johnson Rehabilitation Institute in New Jersey. The brain "is in essence going to develop bad habits."
Sgt. Raymond Hisey, 32, a convoy driver in the 1st Armored Division, survived a roadside blast in Iraq in July 2009. He remained in the field, but endured constant headaches and balance problems. His short-term memory suffered and he struggled to think of words to express himself.
When he returned to Fort Bliss in October, he was diagnosed as having suffered a mild traumatic brain injury and was prescribed several courses of therapy. But a speech therapist cancelled several appointments, he said, and he clashed with the occupational therapist. Hisey was suddenly left without any treatment at all for his symptoms.
"You just get lost in the system," he said. "I could have pushed more, sure. But people kept saying it gets better over time. I thought I was just losing my damn mind, to be honest with you."
Fort Bliss is supposed to provide treatment to troops at smaller bases in the surrounding area. But one such soldier who developed headaches and balance problems after working on a mining detail in Afghanistan was told that no therapists could make regular trips to see him. Instead, the soldier, whose base was about an hour away from Ft. Bliss, was given antidepressants, which he did not take. He recently deployed for a second tour.
"As much as the military is making of TBI and the effects it's having on the soldiers and their families, I think for something as big as Fort Bliss, there'd be more people" to treat it, said the soldier, a specialist who did not want his name used for fear of damaging his career. "I was told there were no resources, no facilities."
Baunchalk, the hospital commander, said he had never heard such complaints from soldiers or their spouses. Soldiers were often reluctant to seek care, he said, because they perceived a stigma attached to traumatic brain injury.
"It's tough for them to step forward and say … I need some help," he said. "I don't think we have that many soldiers who have fallen through the cracks."
Several soldiers told NPR and ProPublica, however, that they and their families had reached out to base commanders, sent e-mails to generals throughout the Pentagon, and even written to members of Congress, pleading for care.
When their efforts proved futile, they felt abandoned. Nobody paid attention, they said, to a soldier with an injury that nobody could see.
"No one listens to the soldier," said Sgt. William Fraas, an 18-year military veteran and Bronze Star recipient who struggled for nearly two years to get help for problems with his balance and vision. "They are there and they are crying for help." The Neurologist
Fort Bliss soldiers struggling with the effects of brain injuries were often sent to Capt. Brett Theeler, the base's sole neurologist. Theeler, records show, sometimes blamed psychological disorders rather than blast wounds as the likely source of soldiers' cognitive problems.
Sgt. Victor Medina suffered brain damage when an IED hit his truck in Iraq.
EnlargeBlake Gordon/Aurora Photos
Sgt. Victor Medina suffered brain damage when an IED hit his truck in Iraq. Even after he was diagnosed with a traumatic brain injury, he found he had to fight to get adequate care.
A convoy commander in the 121st Brigade of the 1st Armored Division, Sgt. Victor Medina can see the moment he suffered his invisible injury. He was rumbling down a highway in southern Iraq June 2009 in a convoy of fuel, ammunition and supplies. Just behind him, in another armored troop carrier, one of Medina's soldiers was videotaping. Suddenly, the screen shakes. Black smoke jets into the air. Noise, swearing, confusion erupts.
A roadside bomb had exploded directly beside Medina. Metal slag ripped through his vehicle's heavy armor, destroying radio equipment and blowing open Medina's door.
Outwardly, Medina did not appear seriously injured. But in the weeks and months that followed, his mind began to fail him. He slurred his words, then started stuttering. An avid reader, he struggled to get through a single page. A punctilious soldier, he began showing up late for missions.
Medina was sent to Germany in August, where Army doctors diagnosed him as suffering from a traumatic brain injury. But when he returned to Fort Bliss for treatment, he and his wife, Roxana, found themselves fighting for care.
Medina had his first appointment with Theeler a month after his return to Ft. Bliss. Afterwards, Theeler wrote that Medina had "multiple cognitive symptoms including poor concentration, short-term memory loss, and difficulty multi-tasking." Theeler said those symptoms were "possibly" related to lingering effects from his concussion, but were "likely" caused by "chronic headaches" and "anxiety." He wrote that Medina's stuttering was probably caused by anxiety, too.
After a follow-up session with Medina in December, Theeler wrote: "I am concerned that he may be slipping into a cycle of playing the sick role." He pointed to the fact that Medina was using crutches — apparently unaware that a physical therapist had asked Medina to use the crutches because of back pain.
To Medina, 34, a tall, broad-chested man with an intense stare, Theeler's words were insulting. Once praised by superiors for his leadership abilities, Medina worked relentlessly to overcome the staccato stutter that had made him difficult to understand. He was fighting to get better, fighting to remain in the Army. He said he felt was being labeled a liar.
"You have all these values that you live for and fight for. And you go to the medical side and you don't see those values," Medina said. "I can understand being injured by insurgents. But I can't understand being injured by my own people."
Other soldiers had similar experiences with Theeler.
By the time Spec. Ron Kapture got to Fort Bliss in July 2009, he had suffered six concussions in which he was knocked unconscious from blasts, according to medical records and his own recollections.
He was suffering headaches on a daily basis. He noticed that he could no longer do simple mental tasks. Before joining the Army, Kapture had gone to vocational school to learn cabinet making. After returning from Iraq, he struggled to put together a bird house with his son.
"It took us about a month," said Kapture, 28. "I could build a whole living room full of furniture in a day seven years ago. It took me a month to build a bird house. That is frustrating stuff."
Brandon Sanford performs balance exercises at Mentis while physical therapist watches
EnlargeBlake Gordon/Aurora Photos
Brandon Sanford performs balance exercises at Mentis while physical therapist Tess Tiscareno watches.
Five months after his return, Kapture finally got an appointment to see Theeler after making repeated requests. Theeler noted that Kapture had a history of "mild concussions," but blamed his cognitive problems on "chronic headaches, sleep disorder and underlying mood anxiety disorders and depressions," records show.
Kapture received counseling and medication for post traumatic stress disorder, or PTSD, but his problems with memory and concentration persisted. He had planned to make the Army his career, but became so embittered at the handling of his care that he is applying for a medical dismissal.
"If that's the best help they … can give us, then God help us all," Kapture said. "If that's the best they have to offer, I feel sorry for the guys coming home."
In an interview at the base, Theeler declined to comment on individual cases, even in cases where soldiers had signed a waiver of their privacy rights. He said, more generally, that he understood why soldiers like Medina and Kapture were frustrated. Mild traumatic brain injury can be difficult to pinpoint as a cause for soldiers' problems since there are no readily available biological markers to indicate that a concussion has occurred, he said.
Theeler said he concentrated on treating soldiers' symptoms regardless of the cause.
Soldiers "say, 'Sir, what's wrong with me?'" Theeler said. "We're honest. I say, 'I don't know what's wrong.' This is an area that we're working very hard at to get our hands around . I don't know the answers." The PTSD Clinic
Some doctors and soldiers at Fort Bliss said medical commanders have placed a higher priority on treating post-traumatic stress disorder, a psychological condition, than on mild traumatic brain injury.
The recently completed Building 805 sits empty at Fort Bliss in El Paso, Texas.
Blake Gordon/Aurora Photos
The recently completed Building 805 sits empty at Fort Bliss in El Paso, Texas. It was supposed to house a clinic for traumatic brain injury. Instead, it has become a symbol for soldiers here of commanders' indifference to their problems.
As evidence, they point to the fate of two clinics. While Building 805 remains unopened, the base has poured money and effort into an experimental PTSD clinic that has attracted widespread attention within the military, including a visit from Defense Secretary Robert Gates.
Known as the Restoration and Resilience Center, the clinic offers intensive, six-month-long treatment for chronic PTSD sufferers, including controversial techniques such as reiki, in which practitioners hover their hands over patients' bodies to improve the flow of "life energy," according to a pamphlet distributed at the center.
Brain injuries and PTSD sometimes share common symptoms and co-exist in soldiers, brought on by the same terrifying events. Neuropsychologists said that treatments for the conditions can differ, however. A typical PTSD program, for instance, doesn't provide cognitive rehabilitation therapy. Someone with nightmares associated with PTSD might be prescribed sleep medication, which could leave a brain-injured patient overly sedated without having a therapeutic effect.
One doctor at Ft. Bliss said that base commanders' focus on the PTSD clinic resulted in soldiers not getting adequate treatment for brain injuries.
"The way our philosophy is in this hospital … we took away their belief that they truly have something," said the doctor, who did not want his name used for fear of retaliation from commanders. "I don't think we gave them the opportunity to heal and that's what I find really disgusting."
Some soldiers said they spent months receiving PTSD treatment while their cognitive problems went unaddressed.
A portrait of William Fraas in his room at Mentis in El Paso.
EnlargeBlake Gordon/Aurora Photos
William Fraas is seen in his room at Mentis in El Paso. Fraas is a Bronze Star recipient who survived several roadside blasts in Iraq. He can no longer drive, or remember simple lists of jobs to do around the house.
Sgt. William Fraas, 38, the sergeant who was awarded the Bronze Star With Valor, served three tours in Iraq, helping to train the Iraqi soldiers as part of the 101st Airborne Division, 320th Field Artillery. He was given his medal after rescuing an Army major and six Iraqi soldiers pinned down by gunfire. Driving in his Humvee, he used to keep track of the roadside bombs with a black grease pencil on the windshield. After 10, he stopped counting.
When he was sent home to Fort Bliss in 2008, he was diagnosed with PTSD and entered the experimental clinic. He spent eight months there before being cleared to return to active duty.
But Fraas realized he was still having problems. He was constantly dizzy. He had debilitating headaches. He would call his wife when driving, so she could keep him oriented and awake.
He began having blackouts. Once, he awoke to find his 12-year-old son struggling to lift him after he collapsed in front of his home computer.
"They have these meetings for PTSD. But nowhere did they tell you anything about TBIs. We had no idea what was going on," he said. "It feels like my head is loose. Like my brain is loose. Like it's rattling inside my head."
William Fraas in Baghdad in 2006 on his second of three tours of duty in Iraq.
Courtesy of William Fraas
William Fraas is seen in Baghdad in 2006 on his second of three tours of duty in Iraq. The photo was taken outside the Italian Embassy after the Italians invited U.S. troops over for pizza.
Finally, last summer, Fort Bliss doctors sent him to see a physical therapist at the base to improve his balance. But the appointments were irregular. And with his inability to drive, he had trouble getting around the sprawling base. A case manager who was supposed to coordinate his care asked one of Fraas' friends if he was faking it. A second case manager never even contacted him.
After putting nearly 20 years into the military, he was stunned.
"I could not get help. I called and called and called. I was hurting," he said. "It was just terrible. I'm a senior non-commissioned officer and I couldn't get help. I couldn't help anywhere." Mentis
Some Fort Bliss soldiers have discovered that if they protest long and loud enough about their care, base commanders occasionally will pay to send them for help — outside the military.
On a hot afternoon earlier this spring, Sgt. Brandon Sanford was digging a small trench in the black soil of a rose garden at Mentis, a private neurological rehabilitation facility perched on the mountains just outside of El Paso.
He was installing an irrigation drip line as part of a therapy program designed to help him follow instructions. He set in one line, then covered up the trench. Then, looking down, he suddenly realized that he had failed to install the second drip line he was holding in his hand.
It was a typical problem for a brain-injury patient. Concentration deficits can make even simple tasks complex and confusing. Sanford immediately began pulling up the first line, digging again.
"That can be frustrating," the therapist overseeing the exercise said sympathetically.
"Never," said Sanford cheerfully. "I ate my Wheaties this morning."
Almost two years ago to the day, Sanford, a dog handler working with the 4th Infantry Division, was inside his Stryker troop carrier near Taji in central Iraq when a bomb exploded. The blast sent Sanford and his dog, Rexo, hurtling against the walls. Both were awarded the Purple Heart for shrapnel wounds they received in the explosion. Although dazed, Sanford shrugged off the headaches and dizziness he experienced and continued working.
When Sanford returned to Fort Bliss in January 2009, he began having seizures, along with continued headaches and balance problems. He saw the base neurologist, Theeler, who diagnosed him as having "shaking syndrome," medical records show.
He entered the PTSD clinic, received counseling and was released, but was still so mentally foggy he couldn't understand his 10-year-old son's math homework. His wife would open the cupboard where they kept cleaning supplies and find that her husband had put the milk carton next to the bleach. Sanford's wife and mother badgered military commanders unrelentingly until, nearly a year after his return from Iraq, they finally sent him to Mentis.
There, Sanford is an in-patient: he spends eight hours a day, five days a week, on rehabilitation exercises. He goes on weekly outings to help him navigate the noise and confusion of public spaces, such as shopping malls. And he practices real-world tasks, like following cooking recipes — or laying out plans for a garden.
Today, Sanford said that he is able to finish making meals more quickly. He can now perform two tasks at once, instead of only one. He is getting better at managing his own medications and his balance has improved.
"You can only do so much sitting inside a hospital. It was like pulling teeth from a tiger to try to get in here. Once I got in here, it was like a whole new ray of light."
Eric Spier, Mentis' medical director, said he has asked the military to send him more patients. But base commanders have sent only a few dozen in almost three years.
"I've made sure to tell everyone I can tell that I'm ready to help, but that's all I can do," Spier said. The base has not sent "very many. It's surprisingly few."
Fraas and Medina now attend sessions at Mentis. They praised the facility, but expressed disappointment that they had had to go outside the Army to receive help.
Medina started in February. The staff at Mentis say his reading and concentration abilities are improving. His growing optimism is apparent in the blog he has started to chronicle his recovery.
"I might be slower right now, but I think it's all going to get better and I want to go back to what I love doing, which is soldiering," Medina said. "It's what I love to do."
PBS - NOVA BRAIN INJURIES SERIES
http://www.pbs.org/wgbh/nova/sciencenow/0306/02.html
ALYSSA'S STORY
BASIC FACTS ABOUT TRAUMATIC BRAIN INJURIES (TBI)
LIVING WITH TRAUMATIC BRAIN INJURY
PEDIATRIC BRAIN INJURY-JOHN HOPKINS
TBI IN SOLDIERS - ABC NEWS
Military Still Failing To Diagnose, Treat Brain Injuries
T. Christian Miller and Daniel ZwerdlingProPublica is a nonprofit investigative news organization.
Based on dozens of interviews and access to previously unreleased military studies, documents and emails, NPR and ProPublica have found that from the battlefield to the homefront the military's doctors and screening systems routinely miss brain trauma in soldiers. As a result, soldiers haven't been getting treatment.
June 7, 2010
The military medical system is failing to diagnose brain injuries in troops who served in Iraq and Afghanistan, many of whom receive little or no treatment for lingering health problems, an investigation by NPR and ProPublica has found.
So-called mild traumatic brain injury has been called one of the wars' signature wounds. Shock waves from roadside bombs can ripple through soldiers’ brains, causing damage that sometimes leaves no visible scars but may cause lasting mental and physical harm.
Officially, military figures say about 115,000 troops have suffered mild traumatic brain injuries since the wars began. But top Army officials acknowledged in interviews that those statistics likely understate the true toll. Tens of thousands of troops with such wounds have gone uncounted, according to unpublished military research obtained by NPR and ProPublica.
"When someone's missing a limb, you can see that," said Sgt. William Fraas, a Bronze Star recipient who survived several roadside blasts in Iraq. He can no longer drive, or remember simple lists of jobs to do around the house. "When someone has a brain injury, you can't see it, but it's still serious."
In 2007, under enormous public pressure, military leaders pledged to fix problems in diagnosing and treating brain injuries. Yet despite the hundreds of millions of dollars pumped into the effort since then, critical parts of this promise remain unfulfilled.
Over four months, we examined government records, previously undisclosed studies and private correspondence between senior medical officials. We conducted interviews with scores of soldiers, experts and military leaders.
Among our findings:
- From the battlefield to the homefront, the military’s doctors and screening systems routinely miss brain trauma in soldiers. One of the military tests fails to catch as many as 40 percent of concussions, a recent unpublished study concluded. A second exam, on which the Pentagon has spent millions, yields results that top medical officials call about as reliable as a coin flip.
- Even when military doctors diagnose head injuries, that information often doesn't make it into soldiers' permanent medical files. Handheld medical devices designed to transmit data have failed in the austere terrain of the war zones. Paper records from Iraq and Afghanistan have been lost, burned or abandoned in warehouses, officials say, when no one knew where to ship them.
- Without diagnosis and official documentation, soldiers with head wounds have had to battle for appropriate treatment. Some received psychotropic drugs instead of rehabilitative therapy that could help retrain their brains. Others say they have received no treatment at all, or have been branded as malingerers.
In the civilian world, there is growing consensus about the danger of ignoring head trauma: Athletes and car accident victims are routinely tested for brain injuries and are restricted from activities that could result in further blows to the head.More About Traumatic Brain Injury
Shifting Numbers
The number of soldiers with mild TBI with lingering problems is open to debate.Graphic: How War Blasts Damage The Brain
An explosion generates a blast wave that travels faster than sound and creates a surge of high pressure.Timeline: Diagnosing the Wars' Signature Injury
Reports of traumatic brain injury affecting soldiers came out as early as 2003. Still, many soldiers are not receiving treatment.Search Documents The Investigation Uncovered
NPR and ProPublica uncovered previously unreleased military studies, documents and emails.'We Still Have A Big Problem'
But the military continues to overlook similarly wounded soldiers, a reflection of ambivalence about these wounds at the highest levels, our reporting shows. Some senior Army medical officers remain skeptical that mild traumatic brain injuries are responsible for soldiers' troubles with memory, concentration and mental focus.
Tell Us Your Story
Did you or a loved one suffer a traumatic brain injury while serving? ProPublica and NPR want to hear you story. Tell us how you survived your battle with TBI.Civilian research shows that an estimated 5 percent to 15 percent of people with mild traumatic brain injury have persistent difficulty with such cognitive problems.
"It's obvious that we are significantly underestimating and underreporting the true burden of traumatic brain injury," said Maj. Remington Nevin, an Army epidemiologist who served in Afghanistan and has worked to improve documentation of TBIs and other brain injuries. "This is an issue which is causing real harm. And the senior levels of leadership that should be responsible for this issue either don't care, can't understand the problem due to lack of experience, or are so disengaged that they haven't fixed it."
When Lt. Gen. Eric Schoomaker, the Army's most senior medical officer, learned that NPR and ProPublica were asking questions about the military’s handling of traumatic brain injuries, he initially instructed local medical commanders not to speak to us.
"We have some obvious vulnerabilities here as we have worked to better understand the nature of our soldiers' injuries and to manage them in a standardized fashion," he wrote in an e-mail sent to bases across the country. "I do not want any more interviews at a local level."
When confronted with the findings later, however, he acknowledged shortcomings in the military's diagnosing and documenting of head traumas.
"We still have a big problem and I readily admit it," said Schoomaker, the Army's surgeon general. "That is a black hole of information that we need to have closed."
Brig. Gen. Loree Sutton, who oversees brain injury issues for the Pentagon, said the military had made great strides in improving attitudes towards the detection and treatment of traumatic brain injury.
The military is considering implementing a new policy to mandate the temporary removal from the battlefield of soldiers exposed to nearby blasts. Later this year, the Pentagon expects to open a cutting-edge center for brain and psychological injuries, which will treat about 500 soldiers annually.
Enlarge Blake Gordon/Aurora Photos for NPR
William Fraas during occupational therapy at Mentis Neuro Rehabilitation Center in El Paso. Fraas survived several roadside blasts in Iraq, but suffered brain damage.
Blake Gordon/Aurora Photos for NPR
William Fraas during occupational therapy at Mentis Neuro Rehabilitation Center in El Paso. Fraas survived several roadside blasts in Iraq, but suffered brain damage.
"This journey of cultural transformation, it is a journey not for the faint of heart," Sutton said. "At the end of our journeys, at the end of our travels, what we must ensure is, we must ensure that we have consistent standards of excellence across the board. Are we there yet? Of course we’re not there yet."
Left Behind
NPR's Steve Inskeep speaks with NPR's Daniel Zwerdling and ProPublica's T. Christian Miller their investigation into how the military has handled the wars' signature injury.
[6 min 5 sec]Soldiers like Michelle Dyarman wonder what’s taking so long. Dyarman, a former major in the Army reserves, was involved in two roadside bomb attacks and a Humvee accident in Iraq in 2005.
Today, the former dean's list student struggles to read a newspaper article. She has pounding headaches. She has trouble remembering the address of the farmhouse where she grew up in the hills of central Pennsylvania.
For years, Dyarman fought with Army doctors who did not believe that she was suffering lasting effects from the blows to her head. Instead, they diagnosed her with an array of maladies from a headache syndrome to a mood disorder.
"One of the first things you learn as a soldier is that you never leave a man behind," said Dyarman, 45. "I was left behind."
In 2008, after Dyarman retired from the Army, Veterans Affairs doctors linked her cognitive problems to her head traumas.
Dyarman has returned to her civilian job inspecting radiological devices for the state, but colleagues say she turns in reports with lots of blanks; they cover for her.
Dyarman’s 67-year-old father, John, looks after her at home, balancing her checkbook, reminding her to turn the oven on before cooking. The joyful, bright child he raised, the first in the family to attend college, is gone, forever gone.
"It hurts me, too," he said, growing upset as he spoke. "That's my daughter sitting there, all screwed up. She's not the kid she was."
Walkie Talkies
Better armor and battlefield medicine mean troops survive explosions that would have killed an earlier generation. But blast waves from roadside bombs, insurgents' most common weapon, can still damage the brain.
The shockwaves can pass through helmets, skulls and through the brain, damaging its cells and circuits in ways that are still not fully understood. Then, secondary trauma can follow, such as sending a soldier tumbling inside a vehicle or hurling into a wall, shaking the brain against the skull.
Not all brain injuries are alike. Doctors classify them as moderate or severe if patients are knocked unconscious for more than 30 minutes. The signs of trauma are obvious in these cases and medical scanning devices, like MRIs, can detect internal damage.
But the most common head injuries in Iraq and Afghanistan are so-called mild traumatic brain injuries. These are harder to detect. Scanning devices available on the battlefield typically don't show any damage. Recent studies suggest that breakdowns occur at the cellular level, with cell walls deteriorating and impeding normal chemical reactions.
Doctors debate how best to categorize and describe such injuries. Some say the term mild traumatic brain injury best describes what happens to the brain. Others prefer to use concussion, insisting the word carries less stigma than brain injury.
Whatever the description, most soldiers recover fully within weeks, military studies show. Headaches fade, mental fogs clear and they are back on the battlefield.
For a minority, however, mental and physical problems can persist for months or years. Nobody is sure how many soldiers who suffer mild traumatic brain injury will have long-term repercussions. Researchers call the 5 percent to 15 percent of civilians who endure persistent symptoms the "miserable minority."
A study published last year in the Journal of Head Trauma Rehabilitation found that, of the 900 soldiers in one battle-hardened Army brigade who suffered brain injuries, almost 40 percent reported having at least one symptom weeks or months later.
The long-term effects of mild traumatic brain injuries can be devastating, belying their name. Soldiers can endure a range of symptoms, from headaches, dizziness and vertigo to problems with memory and reasoning. Soldiers in the field may react more slowly. Once they go home, some commanders who led units across battlefields can no longer drive a car down the street. They can't understand a paragraph they have just read, or comprehend their children's homework. Fundamentally, they tell spouses and loved ones, they no longer think straight.
Such soldiers are sometimes called "walkie talkies" — unlike comrades with missing limbs or severe head wounds, they can walk and talk. But the cognitive impairments they face can be severe.
Enlarge David Gilkey/NPR
Doctor Keith Cicerone works in neuropsychology and cognitive rehabilitation at the JFK-Johnson Rehabilitation Institute in New Jersey. All of his patients have suffered traumatic brain injuries. Doctors at the institute highly recommend cognitive rehabilitation over other forms of treatment.
"These are people who go on to live with a lifelong chronic disability," said Keith Cicerone, a leading researcher in the field. “It is going to be terrifically disruptive to their functioning."
An increasing number of brain-injury specialists say the best way to treat patients with lasting symptoms is to get them into cognitive rehabilitation therapy as soon as possible. That was the consensus recommendation of 50 civilian and military experts gathered by the Pentagon in 2009 to discuss how to treat soldiers.
Such therapy can retrain the brain to compensate for deficits in memory, decision-making and multitasking.
A soldier whose injuries are not diagnosed or documented misses out on the chance to get this level of care — and the hope for recovery it offers, say veterans advocates, soldiers and their families.
"Talk is cheap. It is easy to say we honor our servicemen," said Cicerone, who has helped the military develop recommendations for appropriate treatments for soldiers with brain injuries. "I don’t think the services that we are giving to those servicemen honors those servicemen."
Missing Records
The military’s handling of traumatic brain injuries has drawn heated criticism before.
ABC News reporter Bob Woodruff chronicled the difficulties soldiers faced in getting treatment for head traumas after recovering from one himself, which he suffered in a 2006 roadside bombing in Iraq. The following year, a Washington Post series about substandard conditions at Walter Reed Army Medical Hospital described the plight of several soldiers with brain injuries.
Members of Congress responded by dedicating more than $1.7 billion to research and treatment of traumatic brain injury and post-traumatic stress, a psychological disorder common among soldiers returning from war. They passed a law requiring the military to test soldiers’ cognitive functions before and after deployment so brain injuries wouldn’t go undetected.
But leaders’ zeal to improve care quickly encountered a host of obstacles. There was no agreement within the military on how to diagnose concussions, or even a standardized way to code such incidents on soldiers’ medical records.
Good intentions banged up against the military's gung-ho culture. To remain with comrades, soldiers often shake off blasts and ignore symptoms. Commanders sometimes ignore them, too, under pressure to keep soldiers in the field. Medics, overwhelmed with treating life-threatening injuries, may lack the time or training to recognize a concussion.
The NPR and ProPublica investigation, however, indicates that the military did little to overcome those battlefield hurdles. They waited for soldiers to seek medical attention, rather than actively seeking to evaluate those in blasts.
The military also has repeatedly bungled efforts to improve documentation of brain injuries, the investigation found.
Several senior medical officers said soldiers’ paper records were often lost or destroyed, especially early in the wars. Some were archived in storage containers, then abandoned as medical units rotated out of the war zones.
Lt. Col. Mike Russell, the Army's senior neuropsychologist, said fellow medical officers told him stories of burning soldiers' records rather than leaving them in Iraq where anyone might find them.
"The reality is that for the first several years in Iraq everything was burned. If you were trying to dispose of something, you took it out and you put it in a burn pan and you burned it," said Russell, who served two tours in Iraq. "That’s how things were done."
To improve recordkeeping, medics began using pricey handheld devices to track injuries electronically. But they often broke or were unable to connect with the military's stateside databases because of a lack of adequate Internet bandwidth, said Nevin, the Army epidemiologist.
"These systems simply were not designed for war the way we fight it," he said.
In 2007, Nevin began to warn higher-ups that information was being lost. His concerns were ignored, he said. While communications have improved in Iraq, Afghanistan remains a concern.
That same year, clinicians interviewed soldiers about whether they had suffered concussions for an unpublished Army analysis, which was reviewed by NPR and ProPublica. They found that the military files showed no record of concussions in more than 70 percent of soldiers who reported such injuries to the clinicians.
Nevin said that without documentation of wounds, soldiers could have trouble obtaining treatment, even when they report they can’t think, or read, or comprehend instructions normally anymore.
Doctors might say, "there’s no evidence you were in a blast," Nevin said. “I don’t see it in your medical records. So stop complaining.”
Problems documenting brain injuries continue.
Russell said that during a tour of Iraq last year, he examined five soldiers the day after they were injured in a January 2009 rocket attack. The medical staff had noted shrapnel injuries, but Russell said they failed to diagnose the soldiers' concussions.
The symptoms were "classic," Russell said. The soldiers had "dazed" expressions, and were slow to respond to questions.
"I found out several of them had significant gaps in their memory," Russell said. "It wasn’t clear how long they were unconscious for, but the last thing they remember is they were playing video games. The next thing they remember, they are outside the trailer."
Another doctor told NPR and ProPublica of finding soldiers with undocumented mild traumatic brain injuries in Afghanistan as recently as February 2010.
Enlarge Blake Gordon/Aurora Photos for NPR
Sgt. Victor Medina suffered brain damage when an IED hit his truck in Iraq. As part of a rehabilitation exercise, Jimmy Moody times how long Victor can balance, at the Mentis rehabilitation facility in El Paso, Texas.
Blake Gordon/Aurora Photos for NPR
Sgt. Victor Medina suffered brain damage when an IED hit his truck in Iraq. As part of a rehabilitation exercise, Jimmy Moody times how long Victor can balance, at the Mentis rehabilitation facility in El Paso, Texas.
"It's still happening, there's no doubt," said the military doctor, who did not want to be named for fear of retribution
Screened Out
After the Walter Reed scandal, the military instituted a series of screens to better identify service members with brain injuries. Soldiers take an exam before deploying to a war zone, another after a possible concussion in theater, and a third after returning home.
But each of these screens has proved to have critical flaws.
The military uses an exam called the Automated Neuropsychological Assessment Metrics, or ANAM, to establish a baseline for soldiers’ cognitive abilities. The ANAM is composed of 29 separate tests that measure reaction times and reasoning capabilities. But the military, looking to streamline the process, decided to use only six of those tests.
Doubts immediately arose about the exam, which had never been scientifically validated. Schoomaker, the Army surgeon general, recently told Congress that the ANAM was "fraught with problems" and that "as a screening tool,” it was “basically a coin flip."
Military clinicians have administered the exam to more than 580,000 soldiers, costing the military millions of dollars per year, but have accessed the results for diagnostic purposes only about 1,500 times.
Rep. Bill Pascrell Jr., D-N.J., who has led efforts to improve the treatment and study of brain injuries, accused the military of ignoring the Congressional directive.
"We are not doing service to our bravest," Pascrell said. "There needs to be a sense of urgency on this issue. We are not doing justice."
Once in theater, soldiers are supposed to take the Military Acute Concussion Evaluation, or MACE, to check for cognitive problems after blasts or other blows to the head.
But in interviews, soldiers said they frequently gamed the test, memorizing answers beforehand or getting tips from the medics who administer it.
Just last summer, Sgt. Victor Medina was leading a convoy in southern Iraq when a roadside bomb exploded. He was knocked unconscious for 20 minutes.
Afterwards, Medina had trouble following what other soldiers were saying. He began slurring his words. But he said the medic helped him to pass his MACE test, repeating questions until he answered them correctly.
"I wanted to be back with my soldiers," he said. “I didn't argue about it.".
Senior military officials said problems with the MACE were common knowledge.
"There's considerable evidence that people were being coached or just practicing," said Russell, the senior neuropsychologist. "They don’t want to be sidelined for a concussion. They don’t want to be taken out of play."
If cases of brain trauma get past the battlefield screen, a third test — the post-deployment health assessment, or PDHA — is supposed to catch them when soldiers return home.
But a recent study, as yet unpublished, shows this safety net may be failing, too.
When soldiers at Fort Carson, Colo., were given a more thorough exam bolstered by clinical interviews, researchers found that as many as 40 percent of them had mild traumatic brain injuries that the PDHA had missed.
In a 2007 e-mail, a senior military official bluntly acknowledged the shortcomings of PDHA exams, describing them as "coarse, high-level screening tools that are often applied in a suboptimal assembly line manner with little privacy” and under “huge time constraints."
Col. Heidi Terrio, who carried out the Fort Carson study, said the military's screens must be improved.
"It's our belief that we need to document everyone who sustained a concussion," she said. "It's for the benefit of the Army and the benefit of the family and the soldier to get treatment right away."
Gen. Peter Chiarelli, the Army's second in command, acknowledged that the military has not made the progress it promised in diagnosing brain injuries.
"I have frustration about where we are on this particular problem," Chiarelli said.
Frontline: The Wounded Platoon
This Frontline documentary follows Charlie Company's Third Platoon in Iraq. When the soldiers return home, some adjust well to civilian life, while others struggle with post traumatic stress and traumatic brain injuries. One is in prison, having pled guilty to participation in the murder of another soldier.Watch Frontline's 'The Wounded Platoon'
Fundamentally, he said, soldiers, military officers and the public needed to take concussions seriously.
"We’ve got to change the culture of the Army. We’ve got to change the culture of society," he said, adding later, "We don’t want to recognize things we can’t see."
Skeptics
The shift Chiarelli envisions may be impossible without buy-in from senior military medical officials, some of whom are skeptical about the long-term harm caused by mild traumatic brain injuries.
One of Schoomaker’s chief scientific advisors, retired Army psychiatrist Charles Hoge, has been openly critical of those who are predisposed to attribute symptoms like memory loss and concentration problems to mild traumatic brain injury.
In 2009, he wrote a opinion piece in the New England Journal of Medicine that said the "illusory demands of mild TBI" might wind up hobbling the military with high costs for unnecessary treatment. Recently, Hoge questioned the importance of even identifying mild traumatic brain injury accurately.
"What's the harm in missing the diagnosis of mild TBI?" he wrote to a colleague in an April 2010 e-mail obtained by NPR and ProPublica. He said doctors could treat patients’ symptoms regardless of their underlying cause.
In an interview, Hoge said, "I've been concerned about the potential for misdiagnosis, that symptoms are being attributed to mild traumatic brain injury when in fact they're caused by other" conditions. He noted that a study he conducted, published in the New England Journal of Medicine, "found that PTSD really was the driver of symptoms. That doesn't mean that (mild) TBI isn't important. It is important. It's very important."
Other experts called Hoge’s posture toward mild TBI troubling.
To be sure, brain injuries and PTSD sometimes share common symptoms and co-exist in soldiers, brought on by the same terrifying events. But treatments for the conditions differ, they said. A typical PTSD program, for instance, doesn't provide cognitive rehabilitation therapy or treat balance issues. Sleep medication given to someone with nightmares associated with PTSD might leave a brain-injured patient overly sedated, without having a therapeutic effect.
"I'm always concerned about people trivializing and minimizing concussion," said James Kelly, a leading researcher who now heads a cutting-edge Pentagon treatment center for traumatic brain injury. "You still have to get the diagnosis right. It does matter. If we lump everything together, we're going to miss the opportunity to treat people properly."
The Fight For Treatment
At her family farm outside Hanover, Pa., Michelle Dyarman has a large box overflowing with medical charts, letters and manila envelopes. They are the record of her fight over the past five years to get diagnosis and treatment for her traumatic brain injury.
After her last roadside blast in Baghdad, which killed two colleagues, Dyarman wound up at Walter Reed for treatment of post-traumatic stress.
Over the course of two and a half years, she received drugs for depression and nightmares. She got physical therapy for injuries to her back and neck. A rehabilitation specialist gave her a computer program to help improve her memory.
But it wasn't until she began talking with fellow patients that she heard the term mild traumatic brain injury. As she began to research her symptoms, she asked a neurologist whether the blasts might have damaged her brain.
Records show the neurologist dismissed the notion that Dyarman's "minor head concussions" were the source of her troubles, and said her symptoms were "likely substantially attributable" to PTSD and migraine headaches.
"It was disappointing," she said. "It felt like nobody cared."
When she was later given a diagnosis of traumatic brain injury by Veterans Affairs doctors, she said she felt vindicated, yet cheated all at once.
"I always put the military first, even before my family and friends. Now looking back, I wonder if I did the right thing," she said. "I served my country. Now what's my country doing for me?"
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T. Christian Miller and Daniel ZwerdlingProPublica is a nonprofit investigative news organization.
Based on dozens of interviews and access to previously unreleased military studies, documents and e-mails, NPR and ProPublica have found that from the battlefield to the homefront the military's doctors and screening systems routinely miss brain trauma in soldiers. As a result, soldiers haven't been getting treatment.
Part 1: The military medical system is failing to diagnose brain injuries in troops who served in Iraq and Afghanistan.
Part 2: Even when traumatic brain injury is diagnosed, many soldiers have to fight for adequate treatment.
June 9, 2010
At the rapidly expanding base in Fort Bliss, Texas, along the U.S.-Mexico border, the military is racing to build new homes for 10,000 additional soldiers. Cranes stack prefabricated containers like children's blocks to erect barracks overnight. Bulldozers grind sagebrush desert into roads and runways.
Just down the street from the construction boom squats a tan, featureless building about the size of a convenience store. Completed nearly a year ago, it remains unopened, the doors locked.
Building 805 was supposed to house a clinic for traumatic brain injury, often called the signature wound of the wars in Iraq and Afghanistan. Instead, it has become a symbol for soldiers here of what they call commanders' indifference to their problems.
"The system here has no mercy," said Sgt. Victor Medina, a decorated combat veteran who fought to receive treatment at Fort Bliss after suffering a brain injury during a roadside blast in Iraq last June. Since the explosion, Medina has had trouble reading, comprehending and doing simple tasks. "It's struggle after struggle."
Previously, NPR and ProPublica reported that the military has failed to diagnose brain injuries in troops who served in Iraq and Afghanistan. Mild traumatic brain injuries, which doctors also call concussions, do not leave visible scars but can cause lasting mental and physical problems.
At Fort Bliss, we found that even soldiers who are diagnosed with such injuries often do not receive the treatment they need.
Most specialists say it is critical for patients who show lingering effects from head trauma to get intensive therapy as soon as possible. In the civilian world, such therapy is increasingly seen as the best way to minimize permanent damage, helping to retrain the mind to compensate for deficits.
Yet brain-injured soldiers at Fort Bliss have had to wait weeks and sometimes months just to get appointments with doctors, medical records show. Many have received far less therapy than is typical at well-regarded civilian clinics. In some instances, Fort Bliss medical officers have suggested that the soldiers are malingerers or that the main root of their cognitive problems is psychological.
Getting Care For Traumatic Brain Injury
"Here you have all these soldiers looking for help, and it was just getting swept under the carpet," said Sgt. Brandon Sanford, 28, a dog handler who survived two roadside blasts in Iraq. Sanford endured a year of balance problems and mental fog before Fort Bliss officials sent him for cognitive therapy. "I served my country. I've got an injury to prove it."
It is impossible for civilians to know how Fort Bliss' care for brain-injured soldiers compares in quality or scale to that of other bases. Base officials would not give NPR and ProPublica data on how many soldiers are being treated there and the Pentagon would not provide this information for bases elsewhere.
Tell Us Your Story
Did you or a loved one suffer a traumatic brain injury while serving? ProPublica and NPR want to hear you story. Tell us about your experience with TBI.Fort Bliss — the third-largest base in the U.S. military and a vital nerve center for deploying and returning troops — is supposed to be among the best. In 2007, the Pentagon designated it as one of 20 bases nationally that would develop augmented treatment programs for traumatic brain injury.
Yet while base commanders have spent more than $3 billion to expand and improve Fort Bliss over the past several years, they have directed just $5 million to facilities and clinicians to treat TBI. The program had no full-time director until October 2009. A neuropsychologist was hired only recently, after a two-year search.
Fort Bliss' commander, Maj. Gen. Howard Bromberg, declined repeated requests for an interview. Col. James Baunchalk, the base hospital's commander, acknowledged that the TBI program had encountered some delays, but said that it now had 12 clinicians — four full-time and eight part-time — who were delivering comprehensive care.
"I honestly believe that we've done a good job of meeting the needs for the community," Baunchalk said.
He promised in April that Building 805 would open by the end of May, saying they were just waiting until computer cabling was installed.
Apparently, they missed their deadline. As of early June, the clinic to screen soldiers for traumatic brain injury had not opened its doors to a single patient.
The Soldiers
Traumatic brain injuries are among the most common wounds sustained in Iraq and Afghanistan. Shock waves from bombs can pass through helmets and through the brain. Secondary trauma can occur when soldiers are thrown up against vehicles or walls, shaking the brain again.
Officially, the military says about 150,000 soldiers have suffered some form of brain injury since the wars began. But a 2008 Rand study suggests the toll is much higher, perhaps more than 400,000 troops. The most common type are so-called mild traumatic brain injuries. Most people recover quickly from such injuries, but studies have shown between 5 percent and 15 percent of patients may suffer long-term problems.
More About Traumatic Brain Injury
Shifting Numbers
The number of soldiers with mild TBI with lingering problems is open to debate.Graphic: How War Blasts Damage The Brain
An explosion generates a blast wave that travels faster than sound and creates a surge of high pressure.Timeline: Diagnosing the Wars' Signature Injury
Reports of traumatic brain injury affecting soldiers came out as early as 2003. Still, many soldiers are not receiving treatment.Search Documents The Investigation Uncovered
NPR and ProPublica uncovered previously unreleased military studies, documents and e-mails.NPR and ProPublica interviewed more than a dozen soldiers at Fort Bliss who are among that so-called miserable minority. All were diagnosed by military doctors with at least one mild traumatic brain injury. All had persistent symptoms, ranging from headaches and vertigo to difficulties with memory and reasoning.
They described the bewildering ways in which their injuries had changed them. A sergeant who once commanded 60 men in battle got lost in a supermarket. A soldier who once plotted sniper attacks could no longer assemble a bird house. Most of them did not want their names used, for fear of harm to their military careers.
All felt the treatment they received was inadequate. At leading neurocognitive rehabilitation centers, some patients with mild traumatic brain injury often receive three to six hours a day of therapy for months from teams of highly trained specialists.
By contrast, many soldiers at Fort Bliss attended two to four hours of cognitive treatment per week. For some soldiers, weeks passed by with little or no treatment. The therapists who provided the soldier with speech and occupational therapy for their brain injuries sometimes had only minimal training in cognitive rehabilitation, records show.
Staffing shortfalls also meant soldier had long waits before beginning rehabilitative therapies. While clinical research is still developing, the consensus recommendation of a group of military and civilian experts convened by the Pentagon last year was to provide rehabilitation therapy as promptly as possible.
"The longer you go without therapy, the greater likelihood there is of falling into what I would call a mental disuse syndrome, where the brain is not being used at the same level," said Keith Cicerone, a leading rehabilitation researcher and the director of neuropsychology at the JFK Johnson Rehabilitation Institute in New Jersey. The brain "is in essence going to develop bad habits."
Sgt. Raymond Hisey, 32, a convoy driver in the 1st Armored Division, survived a roadside blast in Iraq in July 2009. He remained in the field, but endured constant headaches and balance problems. His short-term memory suffered and he struggled to think of words to express himself.
When he returned to Fort Bliss in October, he was diagnosed as having suffered a mild traumatic brain injury and was prescribed several courses of therapy. But a speech therapist cancelled several appointments, he said, and he clashed with the occupational therapist. Hisey was suddenly left without any treatment at all for his symptoms.
"You just get lost in the system," he said. "I could have pushed more, sure. But people kept saying it gets better over time. I thought I was just losing my damn mind, to be honest with you."
Fort Bliss is supposed to provide treatment to troops at smaller bases in the surrounding area. But one such soldier who developed headaches and balance problems after working on a mining detail in Afghanistan was told that no therapists could make regular trips to see him. Instead, the soldier, whose base was about an hour away from Ft. Bliss, was given antidepressants, which he did not take. He recently deployed for a second tour.
"As much as the military is making of TBI and the effects it's having on the soldiers and their families, I think for something as big as Fort Bliss, there'd be more people" to treat it, said the soldier, a specialist who did not want his name used for fear of damaging his career. "I was told there were no resources, no facilities."
Baunchalk, the hospital commander, said he had never heard such complaints from soldiers or their spouses. Soldiers were often reluctant to seek care, he said, because they perceived a stigma attached to traumatic brain injury.
"It's tough for them to step forward and say … I need some help," he said. "I don't think we have that many soldiers who have fallen through the cracks."
Several soldiers told NPR and ProPublica, however, that they and their families had reached out to base commanders, sent e-mails to generals throughout the Pentagon, and even written to members of Congress, pleading for care.
When their efforts proved futile, they felt abandoned. Nobody paid attention, they said, to a soldier with an injury that nobody could see.
"No one listens to the soldier," said Sgt. William Fraas, an 18-year military veteran and Bronze Star recipient who struggled for nearly two years to get help for problems with his balance and vision. "They are there and they are crying for help."
The Neurologist
Fort Bliss soldiers struggling with the effects of brain injuries were often sent to Capt. Brett Theeler, the base's sole neurologist. Theeler, records show, sometimes blamed psychological disorders rather than blast wounds as the likely source of soldiers' cognitive problems.
Sgt. Victor Medina suffered brain damage when an IED hit his truck in Iraq. Even after he was diagnosed with a traumatic brain injury, he found he had to fight to get adequate care.
A convoy commander in the 121st Brigade of the 1st Armored Division, Sgt. Victor Medina can see the moment he suffered his invisible injury. He was rumbling down a highway in southern Iraq June 2009 in a convoy of fuel, ammunition and supplies. Just behind him, in another armored troop carrier, one of Medina's soldiers was videotaping. Suddenly, the screen shakes. Black smoke jets into the air. Noise, swearing, confusion erupts.
A roadside bomb had exploded directly beside Medina. Metal slag ripped through his vehicle's heavy armor, destroying radio equipment and blowing open Medina's door.
Outwardly, Medina did not appear seriously injured. But in the weeks and months that followed, his mind began to fail him. He slurred his words, then started stuttering. An avid reader, he struggled to get through a single page. A punctilious soldier, he began showing up late for missions.
Medina was sent to Germany in August, where Army doctors diagnosed him as suffering from a traumatic brain injury. But when he returned to Fort Bliss for treatment, he and his wife, Roxana, found themselves fighting for care.
Medina had his first appointment with Theeler a month after his return to Ft. Bliss. Afterwards, Theeler wrote that Medina had "multiple cognitive symptoms including poor concentration, short-term memory loss, and difficulty multi-tasking." Theeler said those symptoms were "possibly" related to lingering effects from his concussion, but were "likely" caused by "chronic headaches" and "anxiety." He wrote that Medina's stuttering was probably caused by anxiety, too.
After a follow-up session with Medina in December, Theeler wrote: "I am concerned that he may be slipping into a cycle of playing the sick role." He pointed to the fact that Medina was using crutches — apparently unaware that a physical therapist had asked Medina to use the crutches because of back pain.
To Medina, 34, a tall, broad-chested man with an intense stare, Theeler's words were insulting. Once praised by superiors for his leadership abilities, Medina worked relentlessly to overcome the staccato stutter that had made him difficult to understand. He was fighting to get better, fighting to remain in the Army. He said he felt was being labeled a liar.
"You have all these values that you live for and fight for. And you go to the medical side and you don't see those values," Medina said. "I can understand being injured by insurgents. But I can't understand being injured by my own people."
Other soldiers had similar experiences with Theeler.
By the time Spec. Ron Kapture got to Fort Bliss in July 2009, he had suffered six concussions in which he was knocked unconscious from blasts, according to medical records and his own recollections.
He was suffering headaches on a daily basis. He noticed that he could no longer do simple mental tasks. Before joining the Army, Kapture had gone to vocational school to learn cabinet making. After returning from Iraq, he struggled to put together a bird house with his son.
"It took us about a month," said Kapture, 28. "I could build a whole living room full of furniture in a day seven years ago. It took me a month to build a bird house. That is frustrating stuff."
Brandon Sanford performs balance exercises at Mentis while physical therapist Tess Tiscareno watches.
Five months after his return, Kapture finally got an appointment to see Theeler after making repeated requests. Theeler noted that Kapture had a history of "mild concussions," but blamed his cognitive problems on "chronic headaches, sleep disorder and underlying mood anxiety disorders and depressions," records show.
Kapture received counseling and medication for post traumatic stress disorder, or PTSD, but his problems with memory and concentration persisted. He had planned to make the Army his career, but became so embittered at the handling of his care that he is applying for a medical dismissal.
"If that's the best help they … can give us, then God help us all," Kapture said. "If that's the best they have to offer, I feel sorry for the guys coming home."
In an interview at the base, Theeler declined to comment on individual cases, even in cases where soldiers had signed a waiver of their privacy rights. He said, more generally, that he understood why soldiers like Medina and Kapture were frustrated. Mild traumatic brain injury can be difficult to pinpoint as a cause for soldiers' problems since there are no readily available biological markers to indicate that a concussion has occurred, he said.
Theeler said he concentrated on treating soldiers' symptoms regardless of the cause.
Soldiers "say, 'Sir, what's wrong with me?'" Theeler said. "We're honest. I say, 'I don't know what's wrong.' This is an area that we're working very hard at to get our hands around . I don't know the answers."
The PTSD Clinic
Some doctors and soldiers at Fort Bliss said medical commanders have placed a higher priority on treating post-traumatic stress disorder, a psychological condition, than on mild traumatic brain injury.
The recently completed Building 805 sits empty at Fort Bliss in El Paso, Texas. It was supposed to house a clinic for traumatic brain injury. Instead, it has become a symbol for soldiers here of commanders' indifference to their problems.
As evidence, they point to the fate of two clinics. While Building 805 remains unopened, the base has poured money and effort into an experimental PTSD clinic that has attracted widespread attention within the military, including a visit from Defense Secretary Robert Gates.
Known as the Restoration and Resilience Center, the clinic offers intensive, six-month-long treatment for chronic PTSD sufferers, including controversial techniques such as reiki, in which practitioners hover their hands over patients' bodies to improve the flow of "life energy," according to a pamphlet distributed at the center.
Brain injuries and PTSD sometimes share common symptoms and co-exist in soldiers, brought on by the same terrifying events. Neuropsychologists said that treatments for the conditions can differ, however. A typical PTSD program, for instance, doesn't provide cognitive rehabilitation therapy. Someone with nightmares associated with PTSD might be prescribed sleep medication, which could leave a brain-injured patient overly sedated without having a therapeutic effect.
One doctor at Ft. Bliss said that base commanders' focus on the PTSD clinic resulted in soldiers not getting adequate treatment for brain injuries.
"The way our philosophy is in this hospital … we took away their belief that they truly have something," said the doctor, who did not want his name used for fear of retaliation from commanders. "I don't think we gave them the opportunity to heal and that's what I find really disgusting."
Some soldiers said they spent months receiving PTSD treatment while their cognitive problems went unaddressed.
William Fraas is seen in his room at Mentis in El Paso. Fraas is a Bronze Star recipient who survived several roadside blasts in Iraq. He can no longer drive, or remember simple lists of jobs to do around the house.
Sgt. William Fraas, 38, the sergeant who was awarded the Bronze Star With Valor, served three tours in Iraq, helping to train the Iraqi soldiers as part of the 101st Airborne Division, 320th Field Artillery. He was given his medal after rescuing an Army major and six Iraqi soldiers pinned down by gunfire. Driving in his Humvee, he used to keep track of the roadside bombs with a black grease pencil on the windshield. After 10, he stopped counting.
When he was sent home to Fort Bliss in 2008, he was diagnosed with PTSD and entered the experimental clinic. He spent eight months there before being cleared to return to active duty.
But Fraas realized he was still having problems. He was constantly dizzy. He had debilitating headaches. He would call his wife when driving, so she could keep him oriented and awake.
He began having blackouts. Once, he awoke to find his 12-year-old son struggling to lift him after he collapsed in front of his home computer.
"They have these meetings for PTSD. But nowhere did they tell you anything about TBIs. We had no idea what was going on," he said. "It feels like my head is loose. Like my brain is loose. Like it's rattling inside my head."
William Fraas is seen in Baghdad in 2006 on his second of three tours of duty in Iraq. The photo was taken outside the Italian Embassy after the Italians invited U.S. troops over for pizza.
Finally, last summer, Fort Bliss doctors sent him to see a physical therapist at the base to improve his balance. But the appointments were irregular. And with his inability to drive, he had trouble getting around the sprawling base. A case manager who was supposed to coordinate his care asked one of Fraas' friends if he was faking it. A second case manager never even contacted him.
After putting nearly 20 years into the military, he was stunned.
"I could not get help. I called and called and called. I was hurting," he said. "It was just terrible. I'm a senior non-commissioned officer and I couldn't get help. I couldn't help anywhere."
Mentis
Some Fort Bliss soldiers have discovered that if they protest long and loud enough about their care, base commanders occasionally will pay to send them for help — outside the military.
On a hot afternoon earlier this spring, Sgt. Brandon Sanford was digging a small trench in the black soil of a rose garden at Mentis, a private neurological rehabilitation facility perched on the mountains just outside of El Paso.
He was installing an irrigation drip line as part of a therapy program designed to help him follow instructions. He set in one line, then covered up the trench. Then, looking down, he suddenly realized that he had failed to install the second drip line he was holding in his hand.
It was a typical problem for a brain-injury patient. Concentration deficits can make even simple tasks complex and confusing. Sanford immediately began pulling up the first line, digging again.
"That can be frustrating," the therapist overseeing the exercise said sympathetically.
"Never," said Sanford cheerfully. "I ate my Wheaties this morning."
Almost two years ago to the day, Sanford, a dog handler working with the 4th Infantry Division, was inside his Stryker troop carrier near Taji in central Iraq when a bomb exploded. The blast sent Sanford and his dog, Rexo, hurtling against the walls. Both were awarded the Purple Heart for shrapnel wounds they received in the explosion. Although dazed, Sanford shrugged off the headaches and dizziness he experienced and continued working.
When Sanford returned to Fort Bliss in January 2009, he began having seizures, along with continued headaches and balance problems. He saw the base neurologist, Theeler, who diagnosed him as having "shaking syndrome," medical records show.
He entered the PTSD clinic, received counseling and was released, but was still so mentally foggy he couldn't understand his 10-year-old son's math homework. His wife would open the cupboard where they kept cleaning supplies and find that her husband had put the milk carton next to the bleach. Sanford's wife and mother badgered military commanders unrelentingly until, nearly a year after his return from Iraq, they finally sent him to Mentis.
There, Sanford is an in-patient: he spends eight hours a day, five days a week, on rehabilitation exercises. He goes on weekly outings to help him navigate the noise and confusion of public spaces, such as shopping malls. And he practices real-world tasks, like following cooking recipes — or laying out plans for a garden.
Today, Sanford said that he is able to finish making meals more quickly. He can now perform two tasks at once, instead of only one. He is getting better at managing his own medications and his balance has improved.
"You can only do so much sitting inside a hospital. It was like pulling teeth from a tiger to try to get in here. Once I got in here, it was like a whole new ray of light."
Eric Spier, Mentis' medical director, said he has asked the military to send him more patients. But base commanders have sent only a few dozen in almost three years.
"I've made sure to tell everyone I can tell that I'm ready to help, but that's all I can do," Spier said. The base has not sent "very many. It's surprisingly few."
Fraas and Medina now attend sessions at Mentis. They praised the facility, but expressed disappointment that they had had to go outside the Army to receive help.
Medina started in February. The staff at Mentis say his reading and concentration abilities are improving. His growing optimism is apparent in the blog he has started to chronicle his recovery.
"I might be slower right now, but I think it's all going to get better and I want to go back to what I love doing, which is soldiering," Medina said. "It's what I love to do."
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